Pregnant people are at increased risk of developing severe illness from the COVID-19 virus, particularly in those from black, Asian and minority ethnic backgrounds, those living in areas of increased socioeconomic deprivation and those in their third trimester (Royal College of Obstetricians and Gynaecologists (RCOG), 2021). The James Paget University Hospitals NHS Foundation Trust in the east of England is situated within the top 10% of deprived areas (Norfolk Insight, 2021) and has a diverse community that includes pregnant people from a variety of ethnic backgrounds. Since April 2021, pregnant people have been offered the vaccine in line with their age cohort (UK Health Security Agency, 2021). Recent reports have shown one in three pregnant people in hospital with COVID-19 in England required additional respiratory support (33%), more than a third developed pneumonia (37%) and one in seven required intensive care (15%) (NHS England, 2021). However, 98% of pregnant people in hospital because of COVID-19 are unvaccinated (Department of Health and Social Care, 2021a; Public Health England, 2021). The concerning growing evidence base directly contributed to the establishment of a pilot fast-track vaccination clinic for pregnant people at The James Paget University Hospitals NHS Foundation Trust, where uptake for the vaccine in this group was low (only 13 pregnant people received the COVID-19 vaccine between March and April 2021).
This paper describes establishment of the pilot clinic including expansion to the community, and presents the uptake of the vaccine in this group. It is hoped this paper will support other organisations who wish to develop similar practices.
Methods
Stakeholder engagement
The development of the pilot COVID-19 vaccination clinic for pregnant people was conceived between James Paget University Hospitals NHS Foundation Trust maternity services and the Norfolk and Waveney Clinical Commissioning Group in May 2021. The aims of the pilot clinic were to:
- Increase the uptake of the COVID-19 vaccination in pregnant people to reduce the risk of serious complications and/or poor pregnancy outcomes
- Reduce the potential pressure on maternity and neonatal services when caring for seriously unwell pregnant people or caring for a premature baby
- Provide a positive experience for pregnant people and increased confidence in the COVID-19 vaccines
- Identify whether a fast-track vaccination clinic was viable and potentially replicable across the integrated care service.
Stakeholders included in initial discussions were James Paget University Hospitals NHS Foundation Trust maternity service staff, the clinical commissioning group staff, women attending the hospital's maternity services, and the Maternity Voices Partnership group. Box 1 describes suggestions resulting from stakeholder engagement activities.
Box 1.Suggestions arising from stakeholder feedback
- A ‘one-stop shop’ approach to reduce the burden of an extra visit for the vaccination. This should be linked with other routine maternity visits where possible, to provide a reduced parking charge and avoid the burden of arranging additional childcare. Suggested by the Trust, clinical commissioning group and Maternity Voices Partnership
- Clinic should be part of the main vaccination hub on the hospital site. Suggested by the Trust, clinical commissioning group and Maternity Voices Partnership
- Women to be offered the vaccination at their 20 week scan initially. Suggested by the Trust
- The invitation for vaccination, with an accompanying frequently asked questions document, should be sent with all antenatal appointment letters, to allow parents time to reflect and feel informed. Suggested by the Trust, clinical commissioning group and Maternity Voices Partnership
- Offer the vaccination to the family unit. Suggested by the clinical commissioning group
- Create a ‘fast track card’ as a visual indicator to the vaccination hub. Suggested by the Trust
- Provide education to staff about the vaccine advice to ensure advice is consistent. Suggested by the Trust, clinical commissioning group and to comply with the national requirement
- Upskill vaccination centre staff in obstetric basic life support as a safety measure. Suggested by the Trust
- Provide education to pregnant people and their families (verbal and written). Suggested by national requirement, the Trust and Maternity Voices Partnership
- Ensure senior maternity management team runs a 24/7 on call rota so someone is always available to support women, families and those in the vaccination centre. Suggested by the Trust
A co-designed three-phase pathway ensured patient and staff safety, accessibility and informed choices remained at the fore (Figure 1). As a result of the unknown potential uptake response, no timeframe was placed on each phase. Clinical judgement by the maternity teams, reviews of uptake data and the growing evidence base guided decisions for expansion.
Figure 1. The co-designed three-phase development of a pilot COVID-19 vaccination clinic for pregnant people
Establishing the clinic
Within 3 weeks of the stakeholder meeting, a dedicated room for the fast-track vaccination clinic was confirmed and made available within the main vaccination hub on the hospital site. A potential target of 40 pregnant people for vaccination per day (equal to the number of pregnant people that attend the antenatal clinic per day) was discussed with the vaccination hub lead and accounted for in terms of resources (vaccine availability, staffing). No additional resource or capacity was required within the antenatal clinic. Figure 2 describes the pathway process created for phase 1.
Figure 2. Fast-track clinic pathway for phase 1
The head of midwifery and deputy head of midwifery relocated to the vaccination hub for the first clinics for safety and reassurance, then again at weeks 3–4. Obstetricians made themselves available for pregnancy-specific COVID-19 vaccine advice for the families coming through the fast-track route. The maternity senior manager and obstetrician on-call were available to support emergency situations, and the vaccination hub was equipped with additional equipment, such as a wedge and emergency caesarean section pack. Visible, up-to-date ‘resuscitation of pregnant women’ guidelines were displayed for the vaccination hub staff to follow. Infection, prevention and control and vaccine management was covered in the existing vaccination hub standard operating procedure and the new fast-track pathway was reflected in this. Following the national standard operating procedure, the Trust has an internal vaccination clinical incident process in place.
Antenatal clinic staff recorded acceptances of the offer of COVID-19 vaccination and logged this in the maternity electronic notes and recording system (Euroking). Once vaccination was documented on the national immunisation and vaccine system, it was automatically displayed in the GP patient records as per the routine national process. A Microsoft Forms survey with QR code was developed by the vaccination hub to capture feedback from pregnant people. This information helped to identify the impact of communications and aspects of the service, which could be improved in real time. The maternity department volunteer escorted pregnant people to the vaccination hub if required. Upon arrival and showing the red fast-track card, the individual was taken straight through to the dedicated clinic room and given the opportunity to ask more questions. Vaccines were administered by the vaccination hub staff. Second doses were booked during the first vaccine clinic appointment.
Regular promotion of the fast-track clinic included use of social media platforms (Facebook and Twitter) at week three (July 2021) and month two (August 2021), which generated media interest. Question and answer sessions were hosted by the head of midwifery, infertility nurse specialist and associate medical director were undertaken with maternity staff across the region, focusing on ‘real-world’ data education, international research activity and associated results; this appeared to support the confidence of maternity staff.
Results
The first pilot fast-track COVID-19 vaccination clinic for pregnant people was held on 28 June 2021. Phase 2, ‘community expansion’, commenced 29 July 2021. Community midwives provided women and families with COVID-19 vaccination information at their initial antenatal booking appointment, along with a direct link to book into the fast-track COVID-19 vaccination clinic. While the ‘walk-in’ vaccination hub in the local town centre was open from April 2021 (to national age based cohorts), specific promotion for pregnant people (phase 3) took place from 1 August 2021 by the head and deputy head of midwifery.
Between 28 June and 30 September 2021, 27 190 people received COVID-19 vaccines through the vaccination hub. A total of 511 pregnant people were booked to receive maternity care at the Trust, all of whom were offered COVID-19 vaccine information. Almost half of those booked to receive care (221 pregnant people, 43% of those booked) received COVID-19 vaccinations through the fast-track clinics. This means approximately 0.8% of the 12.5% total vaccinations given in the timeframe were provided to pregnant people. Of these, 82 (38.9%) were first dose, 134 were second dose (63.5%) and five (2.4%) were vaccine boosters. Seven (3.32%) of the 221 pregnant people received their first and second doses within the June–September timeframe. As a direct result of the fast-track vaccination clinic pilot, a 20% increased uptake in COVID-19 vaccinations by pregnant people was seen.
Geographical uptake centred on the hospital catchment area in Norfolk and Suffolk. Following traditional media and social media promotion, a number of pregnant people travelled from as far afield as 127 miles (west), 39 miles (north) and 140 miles (south) to receive a vaccination through the clinics. Over half (50.2%) of pregnant people receiving COVID-19 vaccines in the clinics resided in the most severely deprived areas locally, with an index of multiple deprivation level 1–4.
Nearly two-thirds (59%) of pregnant people who provided feedback reported that they would not have taken up the vaccination if they had not had the opportunity to discuss this with their practitioner as part of the fast track vaccination service.
Over half (53%) reported receiving their information from a midwife, 8% from an obstetrician, 9% from their GP and 30% from the vaccination nurse. Some of these included information from more than one source.
Almost all (96%) respondents gave a high rating, with the average rating being 4.86 stars for their experience of the clinic (with 5 stars being the highest rating). The impact of communication, information availability and confidence building provided by the fast-track vaccination clinic as experienced by the pregnant people attending is demonstrated by the participant feedback (Box 2).
Box 2.Feedback from service users
- ‘Brilliant service’
- ‘Lovely people and made me feel at ease’
- ‘They were really kind, gave me lots of time to think’
- ‘Very helpful’
- Got lots of conflicting advice but was quickly spoken to by the midwife who consulted the obstetrician and swiftly got me answers’
- ‘Very well looked after’
- ‘The nurse was fantastic and made sure I had the information I asked for beforehand’
- ‘All staff were brilliant. Friendly, informative and calming’
- ‘A midwife at [the Trust] gave me amazing advice and encouraged me to read some articles which was really helpful’
Discussion
Until real-world data on safety in pregnancy could be collected, pregnant people in the UK were advised not to get vaccinated up until April 2021 (Public Health England, 2021). Since the end of May 2021, the number of pregnant women admitted to hospital with COVID-19 has increased five-fold and 58% of all pregnant women offered the vaccine so far have declined it (RCOG, 2021). RCOG (2021) and the Royal College of Midwives (2021) both now recommend vaccination as one of the best defences for pregnant women against severe COVID-19 infection. The seemingly swift step-change in advice and communication of that advice through media outlets has been a challenge for some, sowing a seed of doubt, while for others, it was a relief and reduction of the burden previously experienced. WHO (2021) has now stated ‘vaccine hesitancy’ to be a global threat to health. For pregnant people, the authors propose vaccine hesitancy to be understandable in the context of conflicting advice and inconsistent available data throughout the pandemic.
With the COVID-19 pandemic unfolding so openly in the media, the general public, including pregnant people, have become more aware of health research activity than ever before. While this has had positive connotations, it has also exacerbated anxieties and fear among pregnant women considering receiving the COVID-19 vaccine, who are responsible not only for their own health, but the health and protection of their unborn child. The evidence base for the use of many medications during pregnancy is poor, with understandable ethical and safety issues for the inclusion of pregnant or breastfeeding people in clinical trials (van der Graaf et al, 2018). As a result, pregnant people tend to be excluded from trials, as they have been for COVID-19 vaccines (Rubin, 2021).
In light of this, accessing clear and consistent advice has been a serious issue for this group. Many women asked questions of the maternity service staff at the authors' Trust such as ‘should I have the vaccination?’, ‘should I wait until the last trimester?’, ‘will I be putting my baby at risk?’ and ‘if I'm at risk, why am I not being prioritised?’. Maternity teams have had difficulty in providing clear guidance or reassurance as answers have been unknown. At The James Paget University Hospitals NHS Foundation Trust, some pregnant people had received their first COVID-19 vaccine before becoming (or knowing they were) pregnant. There was vaccine hesitancy in relation to dose two where people previously certain about receiving the COVID-19 vaccination experienced uncertainty about their decisions when considering the impact on their unborn child. The success of a vaccine depends not only on its efficacy, but on its acceptance in the population and although vaccine hesitancy among the general population appears to be in decline (Office for National Statistics, 2021), these data when applied to pregnant people are currently unknown.
Box 3 shows feedback from users of the clinic in the first 2 weeks. It demonstrates vaccine hesitancy to be evident within the Trust's workforce early in the programme, so instilling confidence in staff as well as in the pregnant community through evidence-based information and trusting relationships has been key to vaccine uptake and confidence. Strong, visible clinical leadership by the head and deputy head of midwifery and obstetricians in the clinic settings and provision of evidence and guidance as clearly and swiftly as possible has contributed to increased confidence among staff and pregnant people. However, changing advice from national bodies continues to generate confusion and suspicion about the COVID-19 vaccination in pregnancy (Department of Health and Social Care, 2021b).
Box 3.Examples of constructive feedback provided by pregnant people attending the fast-track vaccination clinic in the first 2 weeks‘My midwife informed me she had to suggest the vaccine as it's what the NHS recommended, but her personal views were very clear. She was not convinced it was the right thing to do. I needed someone to clearly explain the facts but she was educated. Due to the information changing when I had just over a month left of my pregnancy it caused me so much stress and worry about what to do. I decided to do my own research and spoke to a paramedic, a family friend, in the end who was the only one who gave me the facts I needed. Also the vaccine centre were really amazing.’‘A midwife and [the Trust] gave me amazing advice and encouraged me to read some articles, which was really helpful information but my community midwife was actually on the fence about me getting it so I've had mixed advice.’
The town centre walk-in clinic was created as part of the overarching Trust vaccination hub set-up design, tailored for the local population and not forgetting that the area is one of the top 10% of most deprived areas in England. The authors propose that part of the pilot fast-track vaccination clinic success has been achieved through taking vaccines to areas of need, reducing the burden on travel, transport and finance rather than relying on pregnant people ‘coming to us’. The need to replicate such clinics is evidenced by the distances some pregnant people travelled, despite not being from the Trust, in order to access the clinic. It was the advice, support and informed choice that were cited as key indicators to service users' decisions to attend the clinic, as opposed to attending age-cohort open clinics in their own areas. It would seem reasonable to propose that those travelling this distance, while very welcome to utilise this service, were also only those who had the means to do so (financial, transport etc).
The Trust's community maternity service provides ‘continuity of carer’ teams as part of the Better Births (NHS England, 2016) recommendations, and these teams have been in place for 8 months. This initiative allows provision of care through the same team of midwives through pregnancy, labour and the postnatal period (NHS England, 2016). As a strong trust-based relationship between the midwife and the pregnant person is essential for good care (Mirzaee and Dehghan, 2020), it seems sensible that open and trusting conversations between a midwife and the pregnant person in relation to vaccination was also part of their routine care and provision of maternity information. There appears to be a correlation between the Trust continuity of carer teams and the number, geographic location and ethnicity of pregnant people who have received the COVID-19 vaccine. The authors propose the continuity of carer relationship and the consequent trust built with them has contributed to increased uptake of the COVID-19 vaccination. The identification of apparent correlations in care delivery and vaccine uptake identified as a result of developing this paper has led to the establishment of the ‘midwifery research and evaluation group’. The group is already undertaking a follow-up project focusing on the impact of the continuity of carer initiative and its links to ethnicity, diversity, inclusivity and areas of deprivation and need in healthcare and outcomes. Its results will be published as a follow up piece.
The authors believe the fast-track COVID-19 vaccination clinic for pregnant people to be essential for bridging the healthcare inequality divide that the COVID-19 pandemic has exposed and that it is replicable across integrated care systems.
Conclusions
Vaccine hesitancy is understandable in the context of a pandemic where mixed messaging regarding the safety of the vaccine for pregnant people, whose own health is not mutually exclusive from that of their baby, can cause confusion. The provision of expert advice, complimented by visible, strong leadership and education for both staff and pregnant people, has directly contributed to a 20% increase in COVID-19 vaccine uptake by pregnant people in the Trust. A link between continuity of carer teams and vaccine uptake in areas of deprivation and need appears to be evident; therefore, support for informed decision making and choice requires further exploration.
Key points
- There has been a national increase in pregnant people becoming seriously unwell when contracting COVID-19. Pregnant women with COVID-19 are at a greater risk of admission to intensive care and are 2–3 times more likely to give birth prematurely.
- Pregnant people from black and ethnic minority backgrounds and those from areas of deprivation and need are more likely to become seriously unwell with COVID-19.
- Stakeholder engagement from healthcare professionals, pregnant people and their partners is key to developing a service that is fit for purpose.
- A fast-track vaccination pathway for pregnant people has increased the uptake of COVID-19 vaccines by 20%.
- A trusting relationship between a midwife and pregnant person through the continuity of carer teams appears to correlate with location, ethnicity and inclusion of pregnant people from deprived areas. Further research is required to explore this further.
CPD reflective questions
- What causes vaccine hesitancy amongst pregnant women and their families?
- Why does social or economic background have an impact on vaccine hesitancy?
- Can a woman make a choice about the unborn child without consulting an involved partner around vaccination?
- What differences and challenges does having a continuity of carer relationship in place make to education, trust and decision making?